Immunological status of patients before and after vasovasostomy as determined by the immunobead antisperm antibody test

With the immunobead antisperm antibody test a prospective study was conducted to evaluate the immune status of 55 men before and after vasectomy reversal. A third of the vasectomy patients (19 of 55) had significant serum-sperm antibodies (20 per cent binding or more) detected by the indirect immunobead antisperm antibody test. Of 31 vasovasostomy patients 12 (38 per cent) had significant sperm-surface antibodies (20 per cent binding or more) by the direct immunobead antisperm antibody test. Preoperative serum assays correctly classified the antibody status of 69 per cent of the vasectomy patients. The immunological impact of spermatic granuloma formation, duration of vasal obstruction, patient age and presence of sperm in the vasal fluid at operation also were assessed. An inverse relationship between the proportion of antibody-bound sperm and the percentage of motile sperm in the ejaculate of vas reversal patients was found with videomicrographic semen analysis. The percentage motility was significantly lower among patients with greater quantities of sperm-surface antibodies. No other parameter of semen analysis showed this difference when compared for positive or negative immunobead antisperm antibody test results.     

VASECTOMY REVERSAL ASSOCIATED WITH INCREASED REACTIVE OXYGEN SPECIES PRODUCTION BY SEMINAL FLUID LEUKOCYTES AND SPERM

Purpose

Reactive oxygen species, which are primarily produced by leukocytes, are generally detrimental to sperm. High reactive oxygen species levels are found in men with abnormal sperm function. Since men often have poor sperm characteristics and infertility after vasectomy reversal, fertile men to determine if reactive oxygen species were elevated in the former group.

Materials and Methods

We studied semen samples of men with proved fertility (39) and those with previously proved fertility who had undergone vasectomy reversal (45). The presence of leukocytes was determined by Bryan-Leishman staining. Reactive oxygen species endogenous activity was monitored by luminol dependent chemiluminescence in washed cells, including all cells in the semen, and Percoll density gradient purified sperm.

Results

After vasovasostomy men had significantly lower sperm concentration, motility and computerized motility measurements than fertile men. Mean reactive oxygen species in washed seminal cells after vasovasostomy was 684 relative light units per second compared to 49 for fertile controls (p <0.0001). Density gradient purified sperm had 53 and 0.64 relative light units per second, respectively (p <0.0001). When men with leukocytospermia were excluded from analysis, differences between the groups remained, although 9 times more reactive oxygen species were detected in men after vasectomy reversal with than those without leukocytes in semen.

Conclusions

Higher levels of reactive oxygen species are found in washed seminal cells and purified sperm after vasectomy reversal than in those of fertile men. Although leukocytes are probably a significant source of reactive oxygen species in these groups, they may not account for all of the increased reactive oxygen species after vasovasostomy. Low motility after vasectomy reversal may be related to the detrimental effects of reactive oxygen species produced by leukocytes or sperm, even in men without clinical leukocytospermia.     

Treatment of failed vasectomy reversal using a microsurgical two-layer anastomosis technique

Objective

To evaluate the application of a microsurgical two-layer anastomosis technique in the treatment of failed vasectomy reversal.

Methods

A microsurgical two-layer anastomosis was used in a series of 24 patients with confirmed anastomotic obstruction after previous vasectomy reversal. The patients were followed up for 9 months to 6 years, and the efficacy of the procedure was evaluated by regular seminal analysis and pregnancy records. The results were compared with those obtained from 34 patients who had received primary microsurgical vasovasostomy in our hospital using the same microsurgical technique.

Results

In the treatment group for failed vasectomy reversal patients, the postoperative patency rate was 87.5% (21/24), resulting in a pregnancy rate of 54.2% (13/24). In primary reversal group, the postoperative patency rate was 94.1% (32/34), resulting in a pregnancy rate of 67.6% (23/34). Both the patency and pregnancy rate were not significantly different between these two groups.

Conclusions

The microsurgical vasovasostomy and vasoepididymostomy provided satisfactory patency rate and natural pregnancy rate for patients with a previous failed vasectomy reversal, which is comparable with the results of patients who had undergone primary procedure.     

A Retrospective Review of Factors Associated with Vasovasostomies in United States Military Members

Background

Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal.

Methods

All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed.

Result

A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy.

Conclusion

Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.Key Words: Vasovasostomy, Vasectomy counseling, Demographics, Infertility     

Advances in Male Reproductive Surgery: Robotic-Assisted Vasovasostomy

It is estimated that 3–6% of all vasectomised men request vasectomy reversal for different reasons. Microsurgical vasovasostomy is the gold standard technique of vasectomy reversal. However, the microsurgical technique is time-consuming and challenging to most urological surgeons. Therefore, alternative methods of vasal anastomosis have been studied including robotic-assisted vasovasostomy. This review discusses the feasibility and practice of robotic-assisted vasovasostomy. Based on the available studies robotic-assisted vasovasostomy is feasible. The reported rate of vasal patency associated with this new technique is similar to that of microsurgical vasovasostomy. There is no clear difference between the 2 approaches in terms of operating time. Robotic-assisted vasovasostomy does not appear to afford significant advantages in the era of vasectomy reversal.Key Words: Robotic surgery, Vasectomy reversal, Vasovasostomy     

Analysis of spermatozoa from the proximal vas deferens of vasectomized men

This study assessed the condition of spermatozoa from the proximal vas deferens of men after vasectomy. The fluids of both proximal vas deferens were collected from 67 vasectomized men by cannulating the vas deferens at the time of vasectomy reversal. Selected sperm parameters were analysed after incubation of the spermatozoa for 30 min at 37°C. Spera concentration in the proximal vas from vasectomized men (16 312 ± 21 496 million per ml, geometric mean: 7948 ± 398 million per ml) was significantly higher than that of fertile men and was maintained at a constant level independent of the duration of vas obstruction. The means of sperm motility (36.2 ± 26.2%), spermatozoa with normal morphology (50.7 ± 21.7%), sperm viability (53.0 ± 25.3%) and hypo-osmotic swelling test (HOS-test, 53.9 ± 21.7%) were statistically lower than the respective values for normal fertile men. There was no significant correlation between the duration of vas obstruction and the above semen parameters. In 46.4% of vas fluids all spermatozoa were immotile and this condition was more common after 3 years of vasectomy. Immotile spermatozoa in the proximal vas fluids at the time of vasectomy reversal may be an important factor for predicting semen quality and fertilizing ability after vasovasostomy. There were no significant differences in the results of sperm-cervical mucus penetration test (CMPT) between spermatozoa fiom vasectomized and fertile men. Antisperm antibodies on the surface of spermatozoa from the vas of vasectomized men were determined by the immunobead test (IBT; 78.6% for IgG, 32.1% for IgA) and sperm cervical mucus contact test (SCMC, 36.4%). The presence of antisperm antibodies on the spermatozoa from the vas of vasectomized men may explain, in part, the lower pregnancy rate after vasovasostomy. These parameters of spermatozoa from the proximal vas of vasectomized men may closely reflect those in the cauda epididymis after vasectomy.     

Repeat vasectomy reversal after initial failure: overall results and predictors for success

PURPOSE: We review the treatment outcomes for microsurgical reconstruction following failed vasectomy reversal and identify predictors for success. MATERIALS AND METHODS: We performed a retrospective review of our experience with microsurgical reconstruction in 41 men who underwent 1 or more prior unsuccessful vasectomy reversal procedures. Of these patients 20 underwent bilateral (16) or unilateral (4) vasoepididymostomy, 11 underwent bilateral (7) or unilateral (4) vasovasostomy and 10 underwent unilateral vasoepididymostomy with contralateral vasovasostomy. Postoperative followup consisted of serial semen analyses and telephone interviews. RESULTS: Patency and pregnancy followup data were available in 33 and 31 patients, respectively. Five couples had ongoing uncorrected female factor infertility problems and were not included in pregnancy rate calculations. Mean obstructive interval was 10.6 years. Overall patency and pregnancy rates were 79 and 31%, respectively. Mean total motile sperm count for patients demonstrating patency at followup was 38.0 million. History of conception with the current partner was predictive of future conception with 4 of 5 nonremarried couples (80%) initiating a pregnancy versus 3 of 18 remarried couples (17%) (p = 0.006). Other factors, including smoking history and obstructive interval, did not correlate with postoperative success. Reconstruction with vasovasostomy on at least 1 side trended toward improved patency (p = 0.17) and pregnancy rates (p = 0.15), although they did not assume statistical significance. CONCLUSIONS: Microsurgical reconstruction following failed vasectomy reversal is associated with high patency and moderate pregnancy rates at short-term followup. In our series previous conception with the current partner was predictive of future conception after reconstruction. Urologists performing repeat vasectomy reversal must be familiar with microsurgical techniques, since almost three-quarters of patients will require at least unilateral vasoepididymostomy.     

Differences in the antigen pattern recognized by antisperm antibodies in patients with infertility and vasectomy

PURPOSE: Antisperm antibodies may impair sperm fertilizing capacity. They are found in infertile patients and in men after vasectomy. Little is known to date of the biochemical nature of the antigens that induce the production of antisperm antibodies. MATERIALS AND METHODS: Sperm membrane proteins were prepared from donor spermatozoa, separated by 1-dimensional polyacrylamide gel electrophoresis and exposed to seminal plasma samples of 36 infertile men and 34 after vasectomy containing antisperm antibodies. RESULTS: Ten antigenic protein bands with different molecular weight were recognized by antisperm antibodies. Antisperm antibodies binding to the antigen band at 55 kDa. were significantly more common in infertile men, while those binding to the 72 kDa. band were more common after vasectomy. Significant differences also occurred in the incidence of detecting the 55 kDa. antigen band by the antisperm antibodies of patients with and without varicocele. Comparing antisperm antibodies from patients with or without a history of genital diseases or trauma did not reveal significant differences in the antigens detected. CONCLUSIONS: It seems likely that the development of antisperm antibody binding to different antigens is related to the mode of antibody induction. Since the antigenic properties of spermatozoa change during passage through the epididymis, the antigens detected by antisperm antibodies from men with vasectomy are mostly related to epididymal passage. The identification of human sperm antigens is essential for understanding the mechanism by which antisperm antibodies influence the fertilization capacity of spermatozoa. It is also necessary for the potential development of reliable diagnostic methods for antisperm antibodies that are relevant to infertility.     

Risk factors for male partner antisperm antibodies.

The role of antisperm antibodies in human infertility remains controversial. Indications for antisperm antibody testing of male partners of infertile marriages have been based upon anecdotal reports and studies using outdated assays. In an effort to define the indications for antisperm antibody testing of the male partner, the immunobead assay for antisperm antibodies was performed upon 100 consecutive men referred for evaluation of male factor infertility. The prevalence of antisperm antibodies in this patient population was 18% and only 9% when patients with a history of vasectomy were excluded. Of all the factors analyzed, only a history of vasectomy and sperm agglutination on semen analysis were predictive of antisperm antibody status (p < 0.001). Use of the aforementioned parameters as an indication for antisperm antibody testing would have resulted in a sensitivity of 94%, specificity 73% and negative predictive value 98% in this patient population. The only way to identify all patients with significant levels of antisperm antibody activity (sensitivity 100%) would have been to test every patient.     

SPERM ACROSOME STATUS AND SPERM ANTIBODIES IN INFERTILITY

Purpose

We studied whether the spermatozoa from sperm autoimmune infertile men undergo premature acrosomal loss and whether this relates to the presence of sperm antibodies in wives.

Materials and Methods

We evaluated acrosome status of live washed native and overnight capacitated spermatozoa from 17 sperm nonautoimmune fertile and 23 sperm autoimmune infertile men using an immunofluorescent peanut lectin binding assay. We used cytotoxic and immunobead binding assays to prescreen the serum and seminal plasma of these men, and serum and cervical mucus of the wives for immunological infertility. We performed immunofluorescent sperm antibody assays on all study samples to ascertain sperm antibody isotype levels in each sample. Levels of acrosomal loss in husband native and capacitated spermatozoa were correlated with levels of IgG, IgA and IgM sperm antibodies in the study samples.

Results

Sperm autoimmune infertile men had a significantly larger percentage of sperm (p <0.0001) that had lost the acrosome and a lower percentage of sperm with intact acrosome (p <0.0001) in native and capacitated preparations in contrast to those of fertile controls. Levels of cytotoxic and IgA antibodies, especially in seminal plasma and cervical mucus, correlated significantly with percentages of sperm with a total loss of acrosome in native and capacitated sperm preparations (p [less than =] 0.01).

Conclusion

Infertile men with sperm antibodies in serum and seminal plasma undergo premature acrosome loss. This loss may expose the reproductive tract immune system, especially that involving IgA, in autoimmune infertile men and the wives to high immunogenic levels of sperm acrosome membrane antigens, thereby rendering them immunologically infertile.     

Vasoepididymostomy for Vasectomy Reversal: A Critical Assessment in the Era of Intracytoplasmic Sperm Injection

Purpose

We compared vasoepididymostomy to microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for treatment of epididymal obstruction secondary to vasectomy.

Materials and Methods

Results in patients who underwent vasoepididymostomy for vasectomy reversal at our institution were compared to those reported previously for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection performed for obstructive azoospermia. The pregnancy rates, delivery rates, complications, cost per procedure and cost per delivery were compared. A cost per newborn analysis was performed using pregnancy and delivery rates, and reported cost estimates for the complications of assisted reproductive techniques.

Results

A total of 55 men underwent 58 vasoepididymostomies in an attempt to restore fertility after vasectomy. Median followup was 19 months (range 0 to 115). Median obstructive interval was 12 years. There were no major complications. The patency rate after 6 months was 85%. Of the couples 20 achieved 24 pregnancies and 16 had 17 live births. The pregnancy rate at 1 year was 44%. There were 4 miscarriages and there are 3 ongoing pregnancies. The live delivery rate was 36%. Assuming a 29% delivery rate for microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection, the cost per newborn was $51,024, compared to $31,099 for vasoepididymostomy.

Conclusions

Vasoepididymostomy is more successful and more cost-effective than microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection for vasectomy reversal. It does not expose the women to complications in the treatment of a male problem and it is indicated for treatment of epididymal obstruction secondary to vasectomy. Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection should be reserved for cases not amenable to surgical reconstruction.     

OUTCOME OF MICROSURGICAL RECONSTRUCTION IN MEN WITH SUSPECTED EPIDIDYMAL OBSTRUCTION

Purpose

Approximately 3 to 6% of all men presenting with infertility (excluding those with a history of vasectomy) are suspected of having epididymal obstruction. However, other anatomical abnormalities within the male reproductive tract are often encountered. In this study we attempted to define the range and frequencies of anatomical abnormalities in the reproductive tract and the outcome of surgical reconstruction in men with suspected epididymal obstruction and no history of vasectomy.

Materials and Methods

Between July 1992 and July 1996, 80 azoospermic men with suspected epididymal obstruction underwent scrotal exploration. The anatomical findings and outcomes of reconstructive surgery were reviewed.

Results

Of a possible 160 reproductive tract units (2 per patient) we thoroughly examined 147 with suspected epididymal obstruction. Epididymal obstruction was found in 52.7% of the cases with other anatomical abnormalities accounting for the remaining 47.3%. Of the patients 49 (61%) had sperm identified in the epididymis on at least 1 side and underwent vasoepididymostomy, and 3 (4%) had sperm unilaterally in the proximal vas but had ipsilateral distal vasal obstruction. These 3 men underwent crossed vasovasostomy. We were more likely able to perform reconstruction in men whose obstruction was due to an infectious etiology (13 of 14, 93%) compared to either a surgical (5 of 7, 71%) or idiopathic (34 of 59, 58%) etiology. In 28 patients (35%) no sperm was identified in the epididymis or they had no other abnormalities that precluded successful reconstruction on either side. Of those patients who underwent vasoepididymostomy for epididymal obstruction 61% had sperm in the ejaculate postoperatively.

Conclusions

In nearly half the men with suspected epididymal obstruction other reproductive tract abnormalities were detected, most of which precluded successful vasoepididymostomy. Other reproductive tract abnormalities are much less likely to be found, and the outcomes of reconstruction are better if the cause of the obstruction is infectious compared to surgical or idiopathic.     

Factors predicting success after microsurgical vasovasostomy

Purpose

To identify factors predicting success and analyze critically the status of microsurgical double-layer vasovasostomy using predictive models.

Methods

A cohort of 263 patients treated at our institution for vasectomy reversal between 1986 and 2010 was included in our study, and the literature was reviewed. Inclusion criteria were previous bilateral vasectomy and presence of at least two postoperative semen analyses; patients reporting pregnancy without a postoperative semen analysis were excluded. A double-layer, microscope-assisted, tension-free anastomosis vasovasostomy was performed approximating mucosa to mucosa and muscle to muscle with a 10-0 non-absorbable suture. A multivariate logistic regression backward stepwise model was used to predict combined success, and a predictive model was calculated with remaining variables.

Results

Mean age was of 41.6 years (SD 7.1); mean duration of obstruction 7.2 years (SD 6.7). On multivariate analysis, uni- or bilateral granuloma and Silber grade of I–III were variable identified predicting higher probability to success (OR 3.105; 95% CI 1.108–8.702; p = 0.031 and OR 4.795; 95% CI 2.117–10.860; p < 0.001, respectively).

Conclusions

Based on our results, some factors predicting success after vasovasostomy surgery are known but others remain unknown; our predictive model may easily predict patency and success after this surgery and offers a concrete assistance in counseling patients.

     

Should all urologists performing vasectomy reversals be able to perform vasoepididymostomies if required?

PURPOSE: While vasectomy reversal is a highly successful procedure 10% to 30% of reversals may fail. Despite the general consensus that an epididymal obstruction may occur following a vasectomy and that some men should undergo vasoepididymostomy (VE) rather than vasovasostomy (VV), the practice of many urologists in our region has been to offer only VV for vasectomy reversal. We examined the potential causes for vasectomy reversal failure in patients who had undergone VV without an attempt at VE. MATERIALS AND METHODS: We conducted a retrospective review of patients who had undergone redo vasectomy reversal from January 1999 to September 2001. A total of 22 patients underwent redo reversal with a minimum followup of 2 years. The medical records of all patients were then reviewed. Patients and partners seen postoperatively in the clinic were questioned regarding any pregnancy or deliveries. RESULTS: We examined 22 patients who had undergone redo vasectomy reversal. Of 22 patients 9 (40.9%) underwent repeat VV, 8 (36.3%) underwent bilateral VE for a presumed unrecognized epididymal obstruction and 5 (22.7%) had a combination of VE and VV. Of the 44 reproductive units studied 23 (52.3%) had a failed vasal anastomosis while 21 (47.7%) had an unrecognized epididymal obstruction. Based on semen analysis patency was observed in 75% of patients who had undergone vasovasostomy as a redo procedure. A patency rate of 60% was found in patients who underwent vasoepididymostomy and vasovasostomy unilaterally, and patency rates for bilateral VE were 63%. CONCLUSIONS: Our study indicates that a large proportion of men (48%) have an epididymal obstruction as the etiology for vasectomy reversal failure. We recommend that all surgeons offering vasectomy reversals be able to offer VE if required based on intraoperative findings to serve the patient adequately as well as his partner and their future fertility.     

Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group

During a 9-year period 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm were present in the semen in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses and pregnancy was reported in 52 of 120 couples (43%).     

Failed vasectomy reversal: is a further attempt using microsurgery worthwhile?

OBJECTIVE: To determine, in failed vasectomy reversal, the usefulness of a revised anastomosis using microsurgery in achieving sperm in the ejaculate and fertility, and to relate the outcome to the site of the anastomosis, length of time from vasectomy, and presence or absence of sperm in the vas at surgery. PATIENTS AND METHODS: In a series of 28 patients with confirmed anastomotic obstruction undergoing vasectomy reversal (over a 10-year period), a microsurgical technique using an oblique end-to-end two-layer interrupted anastomosis with 10/0 Nylon was used to establish vasal continuity. Subsequent seminal analysis at 3-6 months and ensuing paternity were related to several variables. The results were compared with those obtained after 137 cases of primary microsurgical vasovasostomy. RESULTS: Sperm was restored to the ejaculate in 16 (57%) of the patients and successful fertilization was reported in nine (32%). The interval between vasectomy and reversal surgery was relevant to the outcome, with four out of four men having sperm in the ejaculate within 5 years and three achieving paternity. However, the fertility rate was still moderate after an interval of 6-10 years (two of six) and at > 10 years (four of 18). The presence of sperm in the ejaculate was related to whether or not sperm were found in the testicular end of the vas at operation, but absence did not preclude a successful outcome. The overall results were not significantly different from those after primary microsurgical reversal surgery. CONCLUSION: Microscopic vasovasostomy after previous obstructive failure provides the patient with a further reasonable chance of becoming fertile; although diminishing with time from vasectomy, even after a prolonged period there can be success. The absence of sperm at the time of vasovasostomy does not necessarily indicate failure, but in these cases the presence of thick creamy fluid in the vas predicts a poor outcome, and alternative methods of management should be considered. A microsurgical technique extending, if necessary, well into the convoluted part of the vas, is recommended. Microsurgical skills, relevant equipment and adequate time are required.     

IgG antisperm antibodies attached to sperm do not correlate with infertility following vasovasostomy

The sperm of 12 men postvasovasostomy was tested for antisperm antibodies by means of a mixed antiglobulin reaction (MAR) test. Agglutinating antibodies were found in 58% of these patients: 50% of the men whose partners became pregnant and 75% of those whose partners did not become pregnant. No significant difference in the level of antibody attachment could be found between the fertile group and the infertile group. Damage to the testis and epididymis following vasectomy seems more likely to interfere with subsequent fertility following vasectomy reversal.     

Microsurgical vasovasostomy after failed vasovasostomy

PURPOSE: We analyzed our experience with repeat microsurgical vasovasostomy after failed vasovasostomy and elucidate the possible predictors of surgical outcome. MATERIALS AND METHODS: We evaluated 62 repeat vasectomy reversal cases with followup data available. Regardless of the intraoperative observation of sperm in the vasal fluid bilateral microsurgical 2-layer vasovasostomy was performed when surgically possible. Of these 62 patients 60 (97%) underwent bilateral (58) or unilateral (2) vasovasostomy and 2 (3%) underwent unilateral vasovasostomy with contralateral epididymovasostomy. RESULTS: Patency and pregnancy followup data were available on 62 and 42 patients, respectively. The overall patency and pregnancy rates achieved were 92% and 57%, respectively, and the natural birth rate was 52%. Increased age of the wife proved a negative prognostic factor for pregnancy (p = 0.018). The intraoperative detection of sperm and other factors, including obstructive interval, reconstruction type, anastomotic site, patient age and postoperative semen parameters, did not influence the surgical outcome. CONCLUSIONS: Regardless of the detection of sperm in the intravasal fluid during the operation repeat microsurgical vasovasostomy resulted in a better outcome than in other studies, in which adopted epididymovasostomy was done when sperm was absent from the vas fluid. Our study suggests that compromised anastomosis after previous surgery is the most common cause of failed vasovasostomy. We recommend that microsurgical vasovasostomy should be performed preferentially in failed vasovasostomy cases.     

SEMINAL TRACT OBSTRUCTION CAUSED BY CHILDHOOD INGUINAL HERNIORRHAPHY: RESULTS OF MICROSURGICAL REANASTOMOSIS

Purpose

Childhood inguinal herniorrhaphy is a frequent causes of seminal tract obstruction. We investigate the characteristics of this obstruction, surgical techniques for reanastomosis and outcomes in patients with bilateral or unilateral obstruction caused by inguinal herniorrhaphy in childhood.

Materials and Methods

We treated 22 men an average of 30.5 years old in whom average duration of obstruction was 27.1 years. Obstruction was bilateral in 9 patients and unilateral in 13, and 14 had azoospermia preoperatively. Microsurgical 2 layer vasovasostomy and/or specific tubule epididymovasostomy was performed.

Results

Inguinal and crossed vasovasostomy was done in 18 and 4 patients, respectively. The distal end of the vas was found at the internal inguinal ring or in the pelvic cavity in 57.1% of the vasa and more than 3 cm. of the vas had been resected in 37%. Sperm was noted in vasal fluid in 45.2% of the vasa during the operation and the patency rate of inguinal vasovasostomy was 88.9%. Ipsilateral epididymovasostomy performed after patent inguinal vasovasostomy in 5 patients with secondary epididymal obstruction resulted in normal sperm density and 3 pregnancies. In 7 men more than 2 procedures were done. There was sperm in the ejaculate in 12 of the 14 patients who had had azoospermia preoperatively and apparently increased sperm density postoperatively in 4 of the 8 who had not had azoospermia preoperatively. Pregnancy was achieved by 7 of the 21 married men (33.3%).

Conclusions

Microsurgical reanastomosis of the seminal tract resulted in high patency and pregnancy rates in cases of seminal tract obstruction caused by childhood inguinal herniorrhaphy. Patients should elect seminal tract reanastomosis or assisted reproductive technology using epididymal or testicular sperm after receiving sufficient information on each treatment modality.     

The incidence and influence upon fertility of antisperm antibodies in seminal fluid following vasectomy reversal

Seminal plasma samples from men undergoing vasovasostomy were analysed for antisperm antibodies using the indirect immunobead test. A pre-operative assessment showed antisperm antibodies of either IgA or IgG class to be present in 9/27 (33.3%) men. A significant increase (P less than 0.05) in the post-operative incidence of the antibodies was seen in the men who achieved patency (27/45, 60%) but not in those men for whom no sperm were seen in the ejaculate (4/10, 40%). After follow-up for a minimum of 1 year, conception rates for couples in which the male partner had achieved patency were similar in the groups with no antibodies detected post-operatively (12/18, 66.7%) or with IgA alone (2/3, 66.7%), but was reduced significantly in the presence of IgG (1/9, 11.1%; P less than 0.05) or IgA + IgG (3/15, 20.0%; P less than 0.01).